Torres-Henderson C, et al,
Proceedings of the 2015
American College of
Veterinary Internal Medicine
Annual Forum
Fenimore L, et al.
Proceedings of the 2012
American College of
Veterinary Internal Medicine
Annual Forum.
Diarrhea is a common side eect
associated with antibiotic use in both
humans and pets. What do we know
about antibiotic use and its eects on
good bacteria, as well as bad?
Antibiotics administered orally can cause gastric
irritation and vomiting, as well as diarrhea associated
with changes to the composition and function of
the gastrointestinal microbiota. Antibiotics such
as amoxicillin-clavulanate and clindamycin are
among those associated with GI side effects.
Just as some people have trouble tolerating
antibiotics while others don’t, not every dog or cat
given antibiotics develops nausea, vomiting or
diarrhea—and the effects from different antibiotics
can also vary. Why this occurs is not fully understood.
Can “good” bacteria be restored by
feeding a probiotic? Does it matter
which probiotic is fed?
Administration of a probiotic (non-pathogenic
bacteria that may have a beneficial effect on the
host) can potentially increase numbers of “good”
bacteria in the gastrointestinal tract. At the
same time, probiotics can reduce the number of
pathogenic (“bad”) bacteria that may be associated
with the development of diarrhea. It’s likely these
effects are specific to certain strains of probiotics.
At Colorado State University, we recently
conducted a study in cats to look at the effects of
Enterococcus faecium strain SF68 on GI clinical
signs associated with amoxicillin-clavulanate, an
antibiotic medication frequently associated with
diarrhea, vomiting and, occasionally, inappetance.
Our goal was to investigate the incidence of
GI side effects associated with the antibiotic’s
administration, as well as potential beneficial
effects from the SF68 probiotic strain.
What was the study protocol and
what were the results?
The study was double-blinded and placebo controlled.
Thirty-four young adult, healthy, mixed-sex cats
were randomized into two rooms and caged so
that clinical findings could be monitored daily for
appetite, aitude, hydration, vomiting and fecal
score, using a scale of 1 to 7 for fecal scoring (1 =
hard and dry; 3 = normal; 7 = watery puddles).
The cats in the study underwent a 10-day
equilibrium period to screen for and eliminate
cats predisposed to stress diarrhea. The remaining
cats were administered amoxicillin-clavulanate
(Clavamox®, Zoetis) at 62.5 mg/cat PO twice a
Michael R. Lappin,
DVM, PhD,
DACVIM
Kenneth W. Smith
Professor,
Small Animal Clinical
Veterinary Medicine
Colorado State University
day for 7 days. Both groups were fed a canned
diet sprinkled with either SF68 (equivalent to
FortiFlora® Feline Probiotic Supplement, Purina®
Pro Plan® Veterinary Diets) or the palatability
enhancer contained in the probiotic supplement
two hours prior to amoxicillin-clavulanate
administration. Clinical scoring continued for the
7 days of treatment and an additional 5 days aer
the antibiotic was stopped.
The results of the study suggested that
amoxicillin-clavulanate can cause gastrointestinal
symptoms and that the concurrent administration
of SF68 may decrease the severity of diarrhea
associated with this antibiotic in some cats
(see Table 1).
What kind of probiotic regimen should
be considered in veterinary patients on
antibiotic therapy?
Minimal studies have been conducted on probiotics
and antibiotic-induced diarrhea, and there are no
standard protocols for this use. In our study, we
chose to administer the probiotic prior to giving
the antibiotic in the hope that the probiotic would
keep the antibiotic from inactivating the probiotic’s
effects. If the antibiotic does not inactivate
the probiotic, it may be possible to administer
them concurrently, as we did successfully in the
treatment of non-specific canine diarrhea with
metronidazole, with and without FortiFlora®.
NUTRITION EXCHANGE
Managing Antibiotic-Induced Diarrhea
Righting the Balance of
Good and Bad Bacteria
1
2
SF68 vs. Placebo in Amoxicillin/
Clavulanate-Treated Cats
Fecal Scores
Table 1
SF68-treated
cats (n=13)
Placebo-treated
cats (n=14)
% of cats % of cats
Fecal score ≥ 5 84.6 85.7
Fecal score ≥ 6 61.5 85.7
Fecal score = 7 -- 21.4
% of total
samples
% of total
samples
Fecal score ≥ 5 43.8 68.4
The stress of environmental
changes and vaccinations
can be tough on rescue
animals, but probiotics
help manage stress-based
diarrhea.
Over-the-counter probiotics, including
yogurt, may have unpredictable
bacterial strains and counts, making
efficacy less predictable.
Can the probiotic survive long
enough to be eective?
Two challenges are associated with
the resiliency of probiotic bacteria.
Veterinary probiotics are dispensed in
an office and then stored in the home,
sometimes for an extended period of
time, so it’s important that the product
be shelf stable. Second, once ingested,
the bacteria need to be able to survive
the harsh, acidic environment of the
stomach. A probiotic that can’t survive
long enough to reach the GI tract won’t
provide any benefit to a pet in need.
FortiFlora is microencapsulated to
withstand handling, processing and
storage to aid in the bacteria’s survival
(see Figure 1). It also carries clear
package dating so clients can trust the
potency of the product they’re feeding.
If they’ve ever taken probiotics
themselves—or at the least heard
their feet by promoting a strong
immune system.
These rescue animals are
going through a lot of stress, both
psychologically and physically.
Vaccinations and spay/neutering can
take a toll on any animal’s health,
particularly those with weakened
immune systems. I advise the shelters
to keep the pets on probiotics
throughout the vaccination schedule
to help manage so stools and stress-
induced diarrhea. If symptoms do
occur, I recommend maintaining
probiotic supplementation until a week
aer signs resolve.
Probiotics have proven to be an
effective tool for pets with GI and
immune health issues. With our clients’
enthusiastic support, we’ve been able
to find a variety of uses for an effective,
easy nutritional supplement.
Key Takeaways
• Probiotics are believed to help to
reduce the severity of antibiotic-
induced diarrhea by increasing
numbers of beneficial bacteria
in the GI tract while reducing
numbers of pathogenic bacteria.
It is believed these effects are
probiotic-specific.
• The efficacy of the SF68
probiotic strain in helping to
reduce the severity of diarrhea
associated with antibiotic
use was demonstrated in an
independent study conducted at
Colorado State University.
• Choosing the right probiotic
for patients is important, as
probiotics may differ in terms
of efficacy and ability to survive
in the harsh environment of the
GI tract.
NUTRITION EXCHANGE
While many clients are familiar with
human probiotics, questions about
how probiotics can benefit their pets
are common.
It may sound obvious, but
not all probiotics are equal and
interchangeable, and it’s important
to make that distinction to owners.
The following three questions can be
helpful in explaining why a specific
probiotic is being recommended.
Is the probiotic safe?
This is an important priority with sick
or immunocompromised patients. It’s
essential that the probiotic selected
to help a pet carry no risk of causing
further disease or worsening
symptoms, particularly by permeating
the intestinal barrier and translocating
bacteria into circulation. If a pet
has a condition that can damage
the intestinal lining (parvovirus
is an example), probiotics may be
contraindicated, due to the potential
for bacteremia development.
Will the probiotic have a
positive impact?
Transient colonization is a key
characteristic of effective probiotics.
As I explain to clients, this means
the bacteria will stick around in
the GI tract and then pass when
supplementation ends. The gut is a
rapidly changing environment that
must be able to adapt, so permanent
colonization of probiotic bacteria is not
desirable.
Along the same lines, the probiotic
can’t compete with the good organisms
in the gut. I tell my clients we want the
probiotic to live in peace with beneficial
bacteria, promoting the production of
short chain fay acids and antibodies
that benefit the pet’s gut and immune
health. For example, Purina® Pro Plan®
Veterinary Diets FortiFlora®
contains the probiotic Enterococcus
faecium strain SF68, which has been
demonstrated to help restore intestinal
health and balance in dogs and cats.
Any approach my clients think will
improve their pets’ health or quality
of life without requiring medication
is likely to interest them. More and
more, owners are seeking alternative
approaches to their pets’ nutrition and
health management. For that reason,
probiotics have become an important
offering in our clinic.
Probiotic use started with
chronic diarrhea management
For years, combining a high-quality diet
and Purina® Pro Plan® Veterinary Diets
FortiFlora® has been an important
component of our approach to the
management of pets with chronic
diarrhea. In pets, this condition is oen
chalked up as a “sensitive stomach”
with recurring rounds of reactive
therapy that can be very frustrating
for pets and owners, particularly in
chronic episodes.
For acute cases, I recommend 10-14
days of FortiFlora added to the diet.
However, chronic cases warrant long-
term probiotic use, which has proven
successful in my experience.
Clinic finds new use for
FortiFlora in shelter pets
Our success using probiotics to help
manage pets with chronic diarrhea
has inspired our clinic to find new
cases, and our work with a local
humane shelter has been the perfect
opportunity. We see a number of
recently rescued dogs and cats with
GI issues, and probiotic supplements
have helped these pets get back on
Talking to Clients:
Are All Probiotics
Created Equal?
Evolving the Use
of Probiotics
Avi Shaprut,
DVM
Veterinary Communications
Manager
Nestlé Purina PetCare
Ashley Gray, DVM
Animal Medical Hospital
Charlotte, North Carolina
them advertised—clients may have
some limited understanding of what a
probiotic is. It’s up to the veterinarian
to educate owners more fully, so
they understand how and why their
pet may benefit from probiotic
supplementation, as well as why the
veterinarian is recommending they
feed a specific product.
FIGURE 1
Microencapsulated Enterococcus
faecium SF68
Our success using probiotics
to help manage pets with
chronic diarrhea has inspired
our clinic to find new cases.
E. facium SF68 in microencapsulated form offers increased stability and viability.
1-2-3s of Probiotic
Assessment
1. Safety - No risk of
causing or worsening
symptoms
2. Beneficial - Promotes
gut and immune health
3. Stable - Survives long
enough to provide benefit
Microencapsulation
Probiotics are widely available for use in dogs and
cats, but quality control of veterinary probiotics is
sometimes poor. In fact, in a recent published article
only 27% of the commercial probiotic products analyzed
contained at least the minimum guaranteed level of
active microorganisms.
25
However, in the development of
FortiFlora, Nestlé Purina formulated the product with
a proprietary microencapsulated microorganism. This
microencapsulation process conserves and protects the
biologically active E. faecium SF68 so it can withstand
handling, processing and storage. The organisms are
encapsulated with a protective coating that is safe for
humans and animals. In the intestinal tract, this coating
completely dissolves and the probiotic becomes available
to the animal. As a result, even at the end of shelf life,
physiologically significant levels of E. faecium SF68 are
consumed by the pet. In addition, mandatory testing
validates probiotic levels and the environment is carefully
controlled during production, distribution and commercial
storage to help minimize losses of E. faecium SF68.
Safety and Tolerance of E. faecium SF68
E. faecium SF68 has a long history of safe use in companion
animals and humans. Since 1985, veterinarians in Austria
and Switzerland have recommended the probiotic for
dogs and cats to help maintain and restore healthy gut
microflora in animals showing disturbances caused by
changes in diet, stress, antibiotic therapy and other factors.
In the United States, E. faecium is considered GRAS
(generally recognized as safe) by the U.S. Food and Drug
Administration (FDA) and is found to present no safety
concerns when used in direct fed microbial products
by the Association of American Feed Control Officials
(AAFCO), based on a safety review by the FDA’s Center for
Veterinary Medicine.
To address potential concerns regarding development of
resistance to antibiotics when probiotics are part of a long-
term diet, European Union researchers reviewed extensive
antibiotic resistance tests and concluded E. faecium SF68
poses no risk when fed. It has been shown that E. faecium
SF68 only transiently colonizes the intestinal tract
and disappears from the tract within a few days after
consumption stops, further emphasizing its safety.
When puppies and kittens were fed either a control diet or
the same diet supplemented with E. faecium SF68, there
were no differences in shedding of potential pathogens
such as haemolytic E. coli, Salmonella and Campylobacter
(Nestlé Purina, internal data, 2003). Hence, E. faecium SF68
is not only safe for the pet, but also for the pet owner who
is handling the product.
See Kayser (2003)
26
for additional information on the
safety of E. faecium SF68.
11
Figure 4: E. faecium SF68 in microencapsulated form offers increased
stability and viability.
MICROENCAPSULATED
ENTEROCOCCUS FAECIUM SF68
153267_Brochure_CC14.indd 11 8/11/15 9:28 PM
Microencapsulation
Probiotics are widely available for use in dogs and
cats, but quality control of veterinary probiotics is
sometimes poor. In fact, in a recent published article
only 27% of the commercial probiotic products analyzed
contained at least the minimum guaranteed level of
active microorganisms.
25
However, in the development of
FortiFlora, Nestlé Purina formulated the product with
a proprietary microencapsulated microorganism. This
microencapsulation process conserves and protects the
biologically active E. faecium SF68 so it can withstand
handling, processing and storage. The organisms are
encapsulated with a protective coating that is safe for
humans and animals. In the intestinal tract, this coating
completely dissolves and the probiotic becomes available
to the animal. As a result, even at the end of shelf life,
physiologically significant levels of E. faecium SF68 are
consumed by the pet. In addition, mandatory testing
validates probiotic levels and the environment is carefully
controlled during production, distribution and commercial
storage to help minimize losses of E. faecium SF68.
Safety and Tolerance of E. faecium SF68
E. faecium SF68 has a long history of safe use in companion
animals and humans. Since 1985, veterinarians in Austria
and Switzerland have recommended the probiotic for
dogs and cats to help maintain and restore healthy gut
microflora in animals showing disturbances caused by
changes in diet, stress, antibiotic therapy and other factors.
In the United States, E. faecium is considered GRAS
(generally recognized as safe) by the U.S. Food and Drug
Administration (FDA) and is found to present no safety
concerns when used in direct fed microbial products
by the Association of American Feed Control Officials
(AAFCO), based on a safety review by the FDA’s Center for
Veterinary Medicine.
To address potential concerns regarding development of
resistance to antibiotics when probiotics are part of a long-
term diet, European Union researchers reviewed extensive
antibiotic resistance tests and concluded E. faecium SF68
poses no risk when fed. It has been shown that E. faecium
SF68 only transiently colonizes the intestinal tract
and disappears from the tract within a few days after
consumption stops, further emphasizing its safety.
When puppies and kittens were fed either a control diet or
the same diet supplemented with E. faecium SF68, there
were no differences in shedding of potential pathogens
such as haemolytic E. coli, Salmonella and Campylobacter
(Nestlé Purina, internal data, 2003). Hence, E. faecium SF68
is not only safe for the pet, but also for the pet owner who
is handling the product.
See Kayser (2003)
26
for additional information on the
safety of E. faecium SF68.
11
Figure 4: E. faecium SF68 in microencapsulated form offers increased
stability and viability.
MICROENCAPSULATED
ENTEROCOCCUS FAECIUM SF68
153267_Brochure_CC14.indd 11 8/11/15 9:28 PM
